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The Problem With Personalized Medicine
gManZboy writes "Talk of individually tailored medical treatment isn't pie in the sky. This approach eventually will help us address risk factors even before a disease can invade our cells, and detect preclinical disease before it gets out of hand. What role will medical informatics play in this brave new world? Hint: Little data projects may be as important as big data projects such as gene sequencing. At a recent symposium on personalized medicine, Ezekiel J. Emanuel, MD, chairman of the Department of Medical Ethics and Health at the University of Pennsylvania, questioned whether it would make more sense to target all the lifestyle mistakes that patients make rather than analyze genetic defects. His view: 'Personalized medicine misses the most important fact about modern society--little ill health and premature death is genetic, much more is lifestyle and social.' Is Emanuel a dinosaur or a pragmatist?"
Everybody knows this, but medicine is a business first. Excuses sell better than solutions. End of story.
So ban HFCS (High Fructose Corn Syrup). It's a vicious cycle - HFCS suppresses the hormone that tells you you're full, so you keep on eating more food with HFCS, further suppressing the "Hey Dummy, Stoppppp!" signal.
Pigs eat corn to fatten up. It has the same long-term effects on humans.
Indeed. Back in the 50s they started telling the world that all fat was unhealthy. People started eating low fat foods, and instead going nuts with sugary drinks/foods, refined carbs and fries. I hate when something says "low fat!" on the front, but it's like 50% sugar. Who cares about the fat content then?
Read up on Ancel Keys and the Seven Countries Study if you want to see where the idea that fat is bad came from.
which is totally what she said
Arguably, targeting things like lifestyle factors is also "personalized medicine", in the sense that treating patient X specially because a defect in their homozygous foo allele predisposes them to cardiac disease isn't all that different from treating patient X specially because getting no exercise predisposes them to cardiac disease.(and, in uncomfortably-many-but-not-all cases, the "personal" element is just the most visible factor in a stew that includes environmental and social influences, like diesel soot and cube farms...)
I'd be inclined to say that Emanuel is neither a dinosaur(he isn't rejecting the new-and-shiny out of hand, just pointing out that much of it offers questionable bang-for-buck compared to the low hanging fruit offered by seriously boring lifestyle stuff), nor a pragmatist(y'know why people like to ignore lifestyle factors and focus on genetic whiz-bangs and hypothetical personalized super-pills? Because lifestyle intervention lies dead at the center of the intersection of "really boring", "really hard", and "lousy patient compliance".
We already have plenty of good advice to go around(by no means perfect knowledge; but we know much better than we do), largely unheeded and often coexisting with social conditions that actively work against heeding it. We don't actually have personalized genetic-super-pills(with limited but important exceptions: oncology, for instance, has a number of genetic markers that have proved tractable to test for and highly useful to know. Some rare hereditary disorders have also been well worked up. Much of the rest of it remains in the "yeah, it sure does appear to run in families; and we made this mouse model by tweaking the genes like so; but that doesn't help you very much...); but we could probably get people to take them fairly regularly if we did...
One of the things 'personalized' medicine addresses is the 'well that's not me' factor that is in may people mind.
The reality is that a percentage of people in the population will never need to worry about cholesterol problems and the knowledge that such people exist allow others to live in the illusion that they may not have to worry about it either.
Personalized medicine will allow the Dr, to tell a person YOU need to not 'X' or you will have 'Y' happen.
The problem however is that it is always a percentage game. Some of the genes we have found so far increase a persons chances of developing a certain type of cancer by 1 or 2 %. So is that enough to warrant changers in behavior.
People who work in computers for a living already know that their carrier choice raises their cancer risk by something like 20% ( how many of them left their careers because of it though).
Part of the problem is understanding the risk ... and them excepting the consequences if they show up.
( are we allowed to do that anymore !!)
âoeTolerance applies only to persons, but never to truth. Intolerance applies only to truth, but never to persons.
Emanuel is right, but experience tells us that people don't want straight-forward advice about not eating deep-fried butter or exercising more. They want to do it anyways and be saved by medicine when it catches up to them.
"If a frog had shock absorbers, it wouldn't bump its butt when it hopped."
Easy to say. It's proved more difficult to actually get people to lose weight.
Give it another few years for Obamacare to come all the way online, and there may well be. ;)
(oblig. "I'll probably get modded down for this.")
Probably. The rest of the modern world all look after the basic medical needs of people, it's pretty much only the US that lets people die because they have no money.
Give it another few years for Obamacare to come all the way online, and there may well be. ;)
(oblig. "I'll probably get modded down for this.")
Probably. The rest of the modern world all look after the basic medical needs of people, it's pretty much only the US that lets people die because they have no money.
I came in to say the same thing Tsingi, there already is a healthcare crisis in the US, and anyone who tells themselves otherwise needs to do some research. The US has been behind in healthcare for years.
1) People who can't afford it and therefore suffer. This includes accidents, communicable diseases, etc. that aren't much dependent on obesity.
2) Huge amounts of resources spent (about half of all healthcare spending) on dragging out the process of dying for people who are, one way or another, going to die soon anyway. Most of them are geriatric patients with incurable progressive conditions: metastatic cancer, congestive heart disease, Alzheimer's, etc.
Better lifestyle practices will give us longer, healthier, and for many of us happier lives. They won't make us invulnerable nor immortal. They won't keep our families from bankrupting themseves trying to add one more week of misery in ICU when our time comes.
Lacking <sarcasm> tags,
...Emanuel seems to be missing it by a mile.
This field is for dealing with the little ugly gaps that neither broad pharmacology nor lifestyle adjustment can correct. Take the case of antidepressants, for example: they're extremely finicky (not all work in all people) and have a huge cost in side-effects before the benefits arise. It is an extremely high cost to both the patient's health and the support system to cope with a bad choice of antidepressant. The basis of this fickleness is genetic, and running the right test in advance can prevent bad combinations.
Personalized medicine is not a cure-all, it's a very precise tool in drug design and selection. I'm sure that won't stop lazy physicians and marketers from calling the regular diagnostic process "personalized," though.
Bio questions? Ask me to start a Q&A journal. Computer analogies available for most topics!
the 'healthcare crisis' is because the nature of healthcare changed and the delivery mechanism did not. In the 1970s, healthcare was very limited. A doctor could set a bone, stitch you up, and blast you with radiation hoping for the best. In 40 years we've moved to things like personalized medicine (where for the price of $10,000 a month an aids patient can thrive, plus a raft of preventative medicines and maintenance medicines. Do you see the shift? We've gone from caring for a few major disasters and making you comfy when you die to maintaining the human body like you would any other machine.
An insurance model for delivering healthcare works for disasters and a one time end of life expense. It breaks when you're using healthcare for maintenance. The thing anyone without socialized medicine is, unless you're so rich you can drop $10k/mo, you don't really have healthcare. Because as soon as you need it, I'm mean you're really going to use it and use it regularly, your insurance provider is going to take it away. That's why America socialized medicine... for the elderly. But even they're going to lose it soon. Just you wait. You think it's there, but it's not. And by the time you realize it, it'll be too late. Poverty will crush you and you won't matter any more. You'll just fall by the way side.
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True, though I don't think it's just that. Any high GI food supplies you energy faster than you can use it. So your body starts storing that excess blood sugar as fat as fast as it can. And then in a little while you're craving energy again, hungry and/or tired. Basically you get sugar withdrawals.
When I tried coming off carbs out of interest, I started in the evening. I felt incredibly tired the next morning. I went out for a walk (probably a mile or two in total) and was really worried I was going to fall asleep on my feet at one point.. but then by the end of the walk I felt good. Basically I think that was because if you exercise for 30 minutes or so you start burning fat for energy rather than relying on stuffing your face. Now I only eat "whole" carbs like brown rice and wholemeal bread/pasta/noodles/whatever. They don't give you the same sugar rushes and cravings that put your body on a chemical rollercoaster.
which is totally what she said
There are examples of people who have been very absusive to their bodies and yet lived long, healthy lives (Ossy, anyone?). There are other people who seem to be cautious enough, yet deal with various health issues. Having better information up front about one's own genetic risks allows for better decisions based on reality, not "professional" opinions founded on years of "experience" of observing the outputs of a very complicated black box by your doctor.
Bottom line, DNA is the source code of how our bodies work. Some may think it is pretty useless at this point, but we will only truly understand its value once we understand it. Most of science works like this . . .
Sdelat' Ameriku velikoy Snova!
Ban? I think just not subsidising it would be a start. The US government spends rather a lot of money paying farmers to grow corn in order to force prices down - and cheap-as-dirt corn is why HFCS is so cheap, and thus so popular in processed foods and snacks.
The goal of personalized medicine is to identify which genomic pattern in a population will respond to a given drug, or identify which drug will work for a given person's genome. It has nothing to do with improving public health policy and only tangentially with reducing health care costs. It has a lot to do with reducing time-to-treatment and making drugs more efficacious.
Emanuel is right that it's nuts to waste money on gene-based treatments which target only the symptoms of disease, when fixing the disease itself necessarily requires a change in lifestyle, which is something that technology cannot and will not fix. Once we accept this, the next step is simply, "How"?
All western countries are healthier than the US. Let's start by looking at what they're doing and then reward americans for doing more of that.
One day, you might be fighting to stay alive too (or maybe you don't think so - but maybe you'll change your mind in 50 years' time).
If I'm still alive at 110, I doubt very much that I'll be all that stressed out about checking out. Plenty of family members have gone peacefully when they got tired of living -- including my maternal (step-)grandmother who basically just withdrew until she shut down and my paternal (step-)grandmother who lived to 97 and got tired of burying children and grandchildren. I think my mother is headed that way soon.
So be it. Give me a good view out over the Rio Grande and some (great-)grandchildren in the house. It's been a blast so far and the rest is gravy.
Lacking <sarcasm> tags,
The GGP said "modern world", which you're comparing to the "underdeveloped world". Therefore your response isn't really a fair one.
Maybe the point should be that only in the US do sick people undergo a lifetime of indentured servitude due to medical bills if they can't pay for insurance. In most other places, people don't have to bundle the choice to receive necessary medical care with the aftermath of crushing medical debt payments for the rest of their lives.
And yes, this issue does cause people to avoid the hospital until a little problem has become a big problem, in many cases fatal. Please refer back to Tsingi's "letting people die" comment. No medical system is perfect, but from my vantage point the American system is pretty messed up.
www.clarke.ca
Indeed. Back in the 50s they started telling the world that all fat was unhealthy. People started eating low fat foods, and instead going nuts with sugary drinks/foods, refined carbs and fries. I hate when something says "low fat!" on the front, but it's like 50% sugar. Who cares about the fat content then?
Yogurt is perhaps the biggest offender on that list. Real natural yogurt usually has a fat content somewhere between 4.5% and 6%. It may be higher, but it is difficult to actually make the yogurt with lower fat content, because it doesn't have the critical mass needed to thicken into something you can eat with a spoon. When you see a yogurt with 2% or lower fat, it's thickened by adding corn starch after the fermentation is completed.
And as others have pointed out, the corn starch and related sugars don't trigger the "I'm full" feeling, so not only are you consuming more calories, you're consuming calories that your body won't recognize as having been consumed... it's less filling and higher calorie density. :(
Just don't get me started on aspartame.
Funnily how people will rabidly fight to preserve every egg that got a sperm in it, right up until the fetus squirts out of a woman's vagina. At that point it's either completely on its own or they actively work to kill it. Right up until it comes down with a terminal illness and wants some "medical lead" to end its suffering. Then it's back to it being immoral and illegal again.
I'm trying to teach myself to set people on fire with my mind... Is it hot in here?
Furthermore, the ER is not the be all and end all of medical care. Treating chronic medical conditions from the ER isn't very useful nor satisfying to either the ER or patient. US FEDERAL LAW STATES ONLY THAT HOSPITALS HAVE TO TREAT PATIENTS FOR EMERGENCY CONDITIONS. Once the "emergency" is over, they don't have to treat you although it is often illegal to just dump a patient out in the street (those tend to be state laws).
And to continue - just because the ER has to treat you doesn't mean the hospital won't bill you. And try to collect on the bill.
So the stupid meme of the US has a health care for all is valid only for a very narrow definition of health care.
And yes, Virginia, there is a crisis in the US healthcare system. Not only do we NOT cover a significant portion of the population, we DO pay more to do so without any measurable benefit whatsoever.
Faster! Faster! Faster would be better!
The metrics that actually matter to the people making use of the system, how more/less likely you are to die of ailment x in country y, shows quite the opposite. If you are diagnosed with any form of Cancer in the US you are more likely to still be alive after 5 years than anywhere else in the world (in some places, such as the UK, the survival rate is half of what it is in the US) and the numbers for almost every other medical problem shows the same pattern with the US being first or top three.
Total bullshit. US cancer death rates are in the middle of the pack on aggregate statistics. Yes, the US does pretty good for some cancers (for some people, most notably those with insurance), but not for all.
Nice of you not to buy insurance when you don't need it. Or don't think you need it. Most people I know don't plan on getting ill. It's not something that is on the calendar for "next year". But keep rolling the dice if you like.
Faster! Faster! Faster would be better!
Just to throw a little fat into the fire, many of those politicians you mentioned crank about renewable energy subsidies as being "market-distorting", and had them high on the chopping block during budget negotiations. At the same time, we also subsidize the hugely profitable petrochemical industries to the tune of more than an order of magnitude greater. Yet that subsidy is "essential" and apparently not at all market distorting.
Specifically, the numbers I've heard were $13e9 for alternative/renewable energy subsidies and $400e9 for petrochemical subsidies.
Since this thread is also focused on corn, it also says nothing about the ill effects that our "corn manipulations" have had on Mexico. Though I'm sure it's an unintended consequence, first the price of corn dropped so low as to drive Mexican farmers out of business, then it bounced back higher than it was before, after the domestic supply was disrupted. Combine that with the side-effects of the War on Drugs, and the US has really screwed over Mexico. Then those same politicians mentioned above get all self-righteous about illegal immigration.
The living have better things to do than to continue hating the dead.
The GI of fructose is 19, the GI of glucose is 100. HFCS is about half of each. If I understand GI correctly, HFCS will probably have a GI around the average of the two, around 60. This is right around the 65 of sucrose. While that is lower than the GI for glucose, it seems to be pretty much where sugars end up. Am I missing something?
HFCS makes you feel hungry, even when you have enough calories, because of the way it acts ont eh bodys hormones. Cane sugar does not. Simple as that.
Part of the reason that the US does as well as it does is because cancer is largely a disease of the elderly. Health care for the elderly is socialized through Medicare. The US is particularly poor on infant mortality because of lack of public services for pregnant women and infants. Extend Medicare to pregnant women and I'll bet that would turn around fast. There's a big US debate about saving random fetuses but the infants and mothers among the uninsured don't seem to show up on the radar very well.
yup, but you are not alone.
Sucrose is a glocose and fructose molecules stuck together. It is rapidly decomposed in the body into.... Glucose and Fructose. So... your body turns sucrose into HFCS. In fact, HFCS was formulated to be similar to sugar that way...on purpose.
So... HFCS is exactly the same as sucrose for most purposes.
However, GI is not the whole story. I highly recomend Lustig's talk on fructose as a poison for a more in-depth discussion (find it on youtube).
Short version.... carbs mostly degrade into glucose over time. every cell of the body, every bacteria, they all process glucose.
Your liver also processes carbs, some of it turns into glucogon, some into vLDL. The difference between fructose and glucose is.... only about 8% of ingested glucose is processed by the liver, whereas 90% of fructose is. Which means much higher vLDL levels (thats the "bad cholesterol" clogging arteries and all that good stuff).
In addition to that, its metabolism also interferes with leptin. This is probably the really important part. Because, leptin is the signal to your brain to supress hunger. It says "done eating, we have enough food". So, this fits in perfectly with studies that showed that a person who drinks a soda (thats takes in hundreds of calories) before a meal actually eats more...which is the opposite of what one would expect from a functioning feedback mechanism.
So not only does sugar/HFCS increase bad cholesterol, and make fat beyond that which other carbs (which mostly turn into glucose) do AND induces a person to eat more.... compounding the issue.
Now... its estimated that the average daily intake of sugar has gone from about 15 g/day (usually with fiber, as most natural sugar sources have fiber too) to over 65 g/day without fiber.
Oh and alcohol? Its a carb too. In fact, there is little difference, to the liver, between alcohol and sugar. Calorie for calorie, they almost have the same effect on the liver.
"I opened my eyes, and everything went dark again"
A ban on all ingredients associated with and linked to obesity should be law.
You are proposing to outlaw almost all foods with calories in them. You can become obese eating almost any energy-dense food -- about 90% of all foods.
It's pretty sad that food clothing and shelter are even an issue in developed countries.
I know a lot about it because I was the one that had to get up at 2 AM to drive her to the fucking E.R. with her son in tow. I worked a night shift the night before and a morning shift the next day so I had all of two hours sleep in a 36 hour period.
The night made a bit of an impression. Between her screaming and crying, and her son crying, and no fucking sleep, I thought I was going to go fucking crazy.
Believe what you want...